Is There Any Benefit From Staged Carotid and Coronary Revascularization Using Carotid Stents?

Abstract

Background and Purpose-To assess the benefits of carotid artery stenting before coronary artery bypass surgery to reduce the risk of stroke occurring during the cardiac procedure. Methods-A prospective cohort study was performed in patients undergoing carotid artery stenting before coronary artery bypass surgery, or combined bypass and valve replacement procedures, to assess the procedures effectiveness in stroke prevention. Outcome measures including 30-day post stenting and cardiac surgery neurological complication and all-cause mortality rates were assessed. Results-A total of 52 patients were included. Two patients underwent aortic valve replacements at the same time as coronary revascularization. No neurological complications occurred because of the stenting procedure. One cardiac death not related to coronary artery bypass surgery occurred in the 30-day follow-up period for the stent procedure. An additional 6 (11.5%) outcome events (3 strokes and 3 deaths) occurred in the 30-day follow-up period after the cardiac procedure. Three patients died of cardiac causes while awaiting their cardiac bypass procedure. Conclusions-Our results are comparable to those in patients that undergo staged or combined carotid endarterectomy before cardiac surgery. Our small cohort study adds to the limited world literature on the subject but is not sufficiently powered to recommend alterations in practice.

Treatment Strategy for Combined Carotid Artery Stenosis and Coronary Artery Disease: Staged or Simultaneous Surgical Procedure?

“…Totally 41,901 patients undergoing simultaneous or staged carotid and coronary procedures were collected from 53 reports (Evagelopoulos et al 2000;Snider et al 2000;Minami et al 2000;Gaudino et al 2001;Hamulu et al 2001;Youssuf et al 2001;Estes et al 2001;Farooq et al 2001;Bonacchi et al 2002;Bonardelli et al 2002;Antunes et al 2002;Zacharias et al 2002;Meharwal et al 2002;Roddy et al 2002;Char et al 2002;Beauford et al 2003;Brown et al 2003;Vitali et al 2003;Ricotta et al 2003;Srimahachota et al 2004;Mishra et al 2004;Ricotta et al 2005;Ziada et al 2005;Cinar et al 2005;Eren et al 2005;Chiappini et al 2005;Akins et al 2005;Nwakanma et al 2006;Inciura and Benetis 2006;Kolh et al 2006;Byrne et al 2006;Cywinski et al 2006;Kovacic et al 2006;Mendiz et al 2006;Randall et al 2006;Chiariello et al 2006;Hertzer and Mascha 2006;Madi-Jebara et al 2006;Kougias et al 2007;Dubinsky and Lai 2007;…”

The Brain First or the Heart: The Approach to Revascularizing Severe Co‐Existing Carotid and Coronary Artery Disease

“…At our institution as illustrated by our case, we recommend a fourth approach, performing staged CAS prior to coronary revascularization (surgical or percutaneous) and believe that this is the safest and most effective approach in high-risk patients especially in the presence of severe bilateral carotid artery disease. 3,8 These patients have a risk for stroke as high as 20% 4 due to fluctuations in blood pressure that might occur during coronary revascularization, and performing staged CAS first minimizes their risk. 11 Twenty three patients underwent staged CABG approximately 70 days after CAS.…”

“…3 The risk for a peri-operative CVA during CABG with a <50% carotid artery stenosis, a severe stenosis (50-80%), and a unilateral occlusion is 1.8%, 10%, and 19% respectively. 3,4 According to the American Heart Association/America College of Cardiology (AHA/ACC) guidelines, the risk for a CVA is as high as 20% in the setting of bilateral severe disease. 4 Conversely, 1 out of 2 patients referred for carotid revascularization has severe epicardial CAD, ischemic electrocardiogram changes, or a history of myocardial infarction (MI).…”

“…One out of 4 patients with multi-vessel CAD has significant carotid artery disease. 3 While approximately 2% of all patients undergoing coronary artery bypass grafting (CABG) suffer from a cerebral vascular accident (CVA), 3 severe carotid artery disease results in a 3 fold increase in the rate of stroke during CABG. 3 The risk for a peri-operative CVA during CABG with a <50% carotid artery stenosis, a severe stenosis (50-80%), and a unilateral occlusion is 1.8%, 10%, and 19% respectively.…”

“…3 While approximately 2% of all patients undergoing coronary artery bypass grafting (CABG) suffer from a cerebral vascular accident (CVA), 3 severe carotid artery disease results in a 3 fold increase in the rate of stroke during CABG. 3 The risk for a peri-operative CVA during CABG with a <50% carotid artery stenosis, a severe stenosis (50-80%), and a unilateral occlusion is 1.8%, 10%, and 19% respectively. 3,4 According to the American Heart Association/America College of Cardiology (AHA/ACC) guidelines, the risk for a CVA is as high as 20% in the setting of bilateral severe disease.…”